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2010 UBO/UBU Conference Title: Electronic Billing — It’s Your Future! Session: T-2-1530.

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Presentation on theme: "2010 UBO/UBU Conference Title: Electronic Billing — It’s Your Future! Session: T-2-1530."— Presentation transcript:

1 2010 UBO/UBU Conference Title: Electronic Billing — It’s Your Future! Session: T

2 Objectives Definition of ‘E-Billing’ Getting Started – How It All Works E-Billing Benefits Your Office National Standards Apply Necessary Elements for Success Advantages Summary & Sources 2

3 Definition Electronic Billing – E-Billing Designed to Transmit Claims in Electronic Format – 837 ASCX12 N 4010 Version – ADM, LAB, RAD Claims 5010 Version Upgrade in 2012 Compliance Based on Clearinghouse – NCPDP 5.1 Version – Pharmacy Claims E-Responses – 835 – Claim Adjudication Response – 270/271 – Electronic Eligibility Check – 276/277 – Electronic Claims Status 3

4 Electronic Billing – 835 Responses Within 24 Hours of Transmission – Payments – Paper EOB – EFT (Electronic Funds Transfer) – Denials – Claims Pended For Information – Errors – Data Elements Expand Reporting Data Analysis 4 Definition

5 Electronic Billing – Pharmacy E-Billing Holding Periods & Timely Filing – 30 Day Filing Deadline – (Majority) – Commercial vs. MTF Pharmacy E-Billing – Statistical Analysis and Data Quality Payer Utilization MTF Utilization of Services Payment and Denial Trends Coding Errors Updates and E-Communication 5

6 Getting Started How It All Works – Enrollment For Payers Create Payer Listing by Utilization Determine Enrollment Requirement Coordinate with Clearinghouse and E-Billing Software Vendor Pharmacy E-Billing May Be a Separate Process – 837 Claims Transmission Clearinghouse Edits (Internal Edits) – Before Claim Goes to Carrier – Research/Fix Edits–Fatal Errors Missing F/L Name of Patient Missing NPI 6

7 How It All Works – 835 Payer Response Edits After Claim Has Reached the Carrier Name and ID Number Mismatch Coverage Terminated Applied to Deductible/Co-Pays Retransmit Corrected Claim Electronic EOBs & Paper EOBs Part of Enrollment Process Depends on E-Billing Vendor Feature 7 Getting Started

8 How It All Works – EFT: Electronic Funds Transfer Commercial Best Practice Funds Electronically Transmitted to U.S. Treasury Copy of EOB/Check Goes to MTF – Electronic Remittance Advice (ERA/835) – Paper EOB Improvements to Processes No More Lost Checks Efficient Record Keeping Staff More Productive Future Is Now! 8 Getting Started

9 E-Billing Benefits Your Office – Creates ‘Paperless’ TPC Office/System Reduces Paper – Clutter – Regular Mail – Spreadsheets – Manual Calculations – Maximizes Staff Increased Efficiency Streamlined Processes Increased Production 9 Benefits

10 E-Billing Benefits Your Office – Electronic Files – 837 and 835 – Efficient Record Keeping Accurate OHI in CHCS – E-Communication with Payer 270/271 – Electronic Eligibility Check 276/277 – Electronic Claims Status – Reporting MTF Specific Clearinghouse 10 Benefits

11 National Standards Apply – Required by HIPAA Sec DHHS – Tasked to Develop – ASC – Accredited Standards Committee – NCPDP – National Council for Prescription Drug Programs – NUBC – National Universal Bill Committee – NUCC – National Uniform Claim Committee – National Standards Are Necessary To Improve the Efficiency and Effectiveness of HealthCare Uniformity Formats Chosen – ASC X12 N Version 4010 Format – NCPDP Version 5.1 Format 11 National Standards

12 Healthcare Electronic Transactions – Claims – Enrollment/Disenrollment In Healthcare Plan – Eligibility – Payment/Remittances/EOBs – Premium Payments – Claims Status – Referral/Certification/Authorization – Coordination of Benefits (COB) HIPAA Standards Web site – 12 National Standards

13 CARDESCRIPTION 1Deductible Amount 2Coinsurance Amount 3Co-payment Amount 90Ingredient cost adjustment. 91Dispensing fee adjustment. 92Claim Paid in full. A1Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remi A2Contractual adjustment. A3Medicare Secondary Payer liability met. A4Medicare Claim PPS Capital Day Outlier Amount. A5Medicare Claim PPS Capital Cost Outlier Amount. A6Prior hospitalization or 30 day transfer requirement not met. A7Presumptive Payment Adjustment A8Ungroupable DRG. B1Non-covered visits. B2Covered visits. B4Late filing penalty. B5Coverage/program guidelines were not met or were exceeded. B6This payment is adjusted when performed/billed by this type of provider, by this type of provider in 13 National Standards

14 Elements for Success Necessary Elements for Success – Open Communication Is IMPERATIVE – Payer Relations Liaison – Vital to the Process – Coordination – MTF – Clearinghouse – Payer – Track Updates – Brief Leadership – Patience Is a Virtue! 14

15 Advantages Brings Billing Office into the 21st Century! Electronic Communication with Payers Speedy Transactions & Responses Positive Impact on A/R – Keeps It Current EFT – Money Is in the Bank! Maximizes Staff 15

16 Summary – Capitalize on E-Billing – Use Clearinghouse for Enrollments – National Standards and Formats – Payer Relations Liaison – Be a Resource to Your Leadership – Have Patience – It’s Worth the Effort! – It’s Your Future! – It’s Now! – Sources Summary & Sources

17 17 Questions


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